Comprehensive Healthcare Inspection Program Review of the Central Texas Veterans Health Care System, Temple, Texas

Report Information

Issue Date
Report Number
18-01137-15
VISN
State
Texas
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Comprehensive Healthcare Inspection Program
Recommendations
18
Questioned Costs
$0
Better Use of Funds
$0
Congressionally Mandated
No

Summary

Summary
The VA Office of Inspector General (OIG) conducted a focused evaluation of the quality of care delivered in the inpatient and outpatient settings of the Central Texas Veterans Health Care System. The review covered key clinical and administrative processes associated with promoting quality care—Leadership and Organizational Risks; Quality, Safety, and Value; Credentialing and Privileging; Environment of Care; Medication Management: Controlled Substances (CS) Inspection Program; Mental Health: Posttraumatic Stress Disorder Care; Long-term Care: Geriatric Evaluations; Women’s Health: Mammography Results and Follow-up; and High-risk Processes: Central Line-associated Bloodstream Infections. The Facility had relatively stable executive leadership and active engagement with employees as evidenced by satisfaction scores. However, opportunities exist to improve outpatient experiences. Additionally, the OIG identified the presence of organizational risk factors with Patient Safety Indicator data and delays in patients receiving sleep apnea equipment, which may contribute to future issues of noncompliance and/or lapses in patient safety unless corrective processes are implemented and continuously monitored. The OIG noted findings in five of the clinical operations reviewed and issued 18 recommendations that are attributable to the Director, Chief of Staff, Associate Director for Patient Care Services, Associate Director, Assistant Director–Austin, and Assistant Director–Waco. The identified areas with deficiencies are: (1) Credentialing and Privileging • Focused and Ongoing Professional Practice Evaluation processes (2) Environment of Care • Personal protective equipment accessibility • Environmental cleanliness • Medical equipment availability • Panic alarm testing and follow-up • Annual Emergency Operations Plan reviews (3) Medication Management: CS Inspection Program • Monthly and quarterly reports • CS inspectors’ appointments • Monthly area inspections • Verification of drugs held for destruction and hard copy prescriptions • Prescription pad accountability (4) Women’s Health: Mammography Results and Follow-up • Communication of results to patients (5) High-risk Processes: Central Line-associated Bloodstream Infections • Staff education

Open Recommendation Image, SquareOpenClosed and Implemented Recommendation Image, CheckmarkClosed-ImplementedNot Implemented Recommendation Image, X character'Closed-Not Implemented
No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Chief of Staff ensures Service Chiefs include clearly delineated timeframes in practitioners’ Focused Professional Practice Evaluation competency reviews and monitors compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Chief of Staff ensures Service Chiefs present the results of completed Focused Professional Practice Evaluations to the Medical Staff Executive Council to recommend continuing the initially granted privileges and monitors compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Chief of Staff ensures Service Chiefs include service-specific data in Ongoing Professional Practice Evaluations and monitors compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Chief of Staff ensures that the Chief, Pathology and Laboratory Medicine Service, includes the required pathology-specific criteria, as applicable, in pathology practitioners’ Ongoing Professional Practice Evaluations and monitors compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Associate Director ensures personal protective equipment is readily accessible and monitors compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Assistant Director–Waco ensures that a clean environment is maintained throughout the Facility and monitors compliance.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Associate Director and Assistant Director–Austin ensure that prescribed sleep apnea equipment is furnished timely to patients and monitor compliance.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Associate Director ensures VA Police and Security Service regularly test panic alarms and take follow-up actions for identified deficiencies at the Austin Community Based Outpatient Clinic and monitors compliance.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Associate Director ensures VA Police and Security Service regularly test panic alarms and take follow-up actions for identified deficiencies at the Waco campus locked mental health unit and monitors compliance.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Assistant Director–Waco ensures that the Emergency Operations Plan is reviewed annually by the Emergency Management Committee and approved by executive leadership and monitors compliance.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Facility Director ensures that the Controlled Substance Coordinator completes monthly summary of findings and quarterly trend reports and monitors compliance.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Facility Director ensures that Controlled Substances Inspectors are appointed in writing prior to performing inspector duties and monitors compliance.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Facility Director ensures that Controlled Substances Inspectors complete routine monthly controlled substances inspections and monitors compliance.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Facility Director ensures that Controlled Substances Inspectors verify drugs held for destruction during monthly inspections at the Waco inpatient pharmacy and monitors compliance.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Facility Director ensures Controlled Substances Inspectors complete pharmacy prescription pad inventories during monthly pharmacy inspections at the Waco outpatient pharmacy and monitors compliance.
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Facility Director ensures that Controlled Substances Inspectors verify evidence of written prescriptions for non-electronic controlled substance orders during monthly area inspections at the Temple outpatient pharmacy and monitors compliance.
No. 17
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Chief of Staff ensures providers or designees communicate mammogram results to patients and monitors compliance.
No. 18
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Associate Director for Patient Care Services ensures that all registered nurses involved in managing central lines receive the required central line-associated bloodstream infection prevention education and monitors compliance.